This inspection took place on the 7 and 8 March 2018 and was unannounced.

Lyme House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Lyme House accommodates up to 21 people with a diagnosis of an acquired brain injury (ABI). The home is part of the transitional rehabilitation unit group (TRU). There were 13 people living at the home at the time of our inspection. The home is situated in the Haydock area.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the last inspection on 25 and 28 April 2017 we found that there were a number of improvements needed in relation to safe care and treatment and good governance. These were breaches of Regulation 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Following the last inspection, we asked the registered provider to complete an action plan to demonstrate what they would do and by when to improve the key questions Safe and Well-led to at least good. The provider sent us an action plan which specified how they would meet the requirements of the identified breaches. During this inspection we found that all required improvements had been made.

This inspection was carried out to check the improvements that had been made by the registered provider to meet the legal requirements after the comprehensive inspection undertaken April 2017. The team of two inspectors inspected the service against all the five questions Safe, Effective, Caring, Responsive and Well-led. We found that the registered provider was meeting all of the legal requirements.

Improvements had been made to the management of medicines and the completion of required documentation. Medicines were ordered, stored, administered in accordance with good practice guidelines by competent staff that had received appropriate training.

Improvements had been made to the governance systems undertaken by the registered provider at the home. Regular audits were undertaken, analysis was completed and areas for development and improvement were identified and actioned.

Safe recruitment procedures were evidenced and sufficient numbers of staff were available to meet the assessed needs of the people living at the home. A comprehensive induction had been completed by all staff. Staff had received training appropriate to their role which was regularly updated. Staff were supported in their roles and attended regular team meetings and shift handovers.

Staff had all received up-to-date safeguarding training and understood their responsibility to raise any concerns about the people they supported. The registered provider had clear safeguarding policies and procedures in place.

People’s needs were assessed before they moved into the home and this information was used to create detailed risk assessments and individual person centred care plans. People’s independence was promoted throughout all documentation. All documents were reviewed regularly and amended when there were any changes to people’s needs.

People’s needs that related to age, disability, religion or other protected characteristics were considered throughout the assessment and care planning process.

People had access to activities of their choice, college placements and vocational opportunities. The management team had developed positive relationships with local community organisations.

Staff had developed positive relationships with the people they supported. People told us their right to privacy and dignity was respected

The inspection took place on 25 and 28 April 2017. The first day was unannounced.

Lyme House is part of the Transitional Rehabilitation Unit group (TRU). The service provides rehabilitation for up to 21 people with a diagnosis of an acquired brain injury (ABI). There were 14 people using the service at the time of our inspection.

The service has a registered manager in post. The registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

During our inspection we found two breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014. You can see the action we have asked the registered provider to take at the end of the report.

The registered provider had medicines policies and procedures in place, however these were not safely followed. Medication administration records were not accurately completed. Medication errors had not been investigated in line with the registered provider’s procedures.

Quality assurance audits did not consistently identify risks within the service. Audit systems did not demonstrate actions completed or timescales for completion and they failed to show who was responsible for actions. Systems did not identify where improvements were required or any patterns or trends in order to prevent accidents or incidents from re-occurring.

Staff recruitment procedures were robust and appropriate checks were carried out prior to staff starting their employment. All staff received a thorough induction that included shadowing an experienced member of staff. All staff undertook mandatory training at regular intervals to ensure they remained up-to-date with their knowledge and skills.

There were sufficient numbers of staff to safely meet the needs of the people living at the service. People told us there were always staff available to meet their individual needs.

Staff had received safeguarding training, and they described the signs that may indicate abuse was taking place. Staff demonstrated a good understanding of the procedures that needed to be followed in the event of a safeguarding alert needing to be raised with the local authority.

People had their needs assessed prior to living at the service and were involved in the development of their care plans. Staff had access to comprehensive care plans and risk assessments which gave them clear direction about how to meet a person’s individual needs and all care plans were reviewed regularly.

People’s dietary needs and preferences were met. Care plans clearly documented the support people required. People were supported to prepare their own food and drink where possible.

People told us that they had regular staff supporting them and they were caring in their approach. We observed positive relationships between people and staff.

The Care Quality Commission are required by law to monitor the operation of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. We saw the policies and guidance were available to all staff in relation to the MCA and DoLS. Staff had undertaken training and demonstrated an understanding of this. People’s care records demonstrated their involvement in decision-making processes. Mental capacity assessments were in place and best interests meetings were clearly documented for people who lacked capacity.

People and their family members knew how to raise concerns or complaints and felt confident to do so. People felt the registered manager was approachable and want endeavour to resolve any concerns or complaints.

Lyme House is part of the Transitional Rehabilitation Unit group (TRU). The service provides rehabilitation for up to 21 people with a diagnosis of an Acquired Brain Injury (ABI).

This was an unannounced inspection carried out by an Adult Social Care inspector. During the inspection we spoke with five people who lived at the service, four members of staff and the registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We observed care and support in communal areas, spoke with people in private and looked at care and management records.

We saw that medicines was not always managed safely or given in a manner that met people’s individual needs.

Some of the systems used to assess the quality of the service had not identified the issues that we found during the inspection. The majority of these were discussed with the registered manager who immediately put new systems into place.

People told us that they had been included in planning and agreeing to the care and support provided. We saw that people had an individual plan, detailing the support they needed and how they wanted this to be provided.

People told us that they were treated with kindness, compassion and respect. We saw many positive interactions and people enjoyed talking to the staff in the home.

Staff we spoke with recognised the importance of knowing people’s routines, so that, people received personalised support.

Staff met with people regularly, took the time to get to know them and supported them in undertaking activities according to their hobbies and interests.

Systems were in place that supported and encouraged people to share their views of the service they received. However, we did not see that the views of relatives had been sought.

People told us they were able to see their friends and families as they wanted. We saw that there were arrangements in place to support people living in the service to access the community and maintain relationships with their families.

The staff told us they were aware of their responsibility to protect people from harm or abuse. They knew the action to take if they were concerned about the safety or welfare of an individual. They told us they would be confident in reporting any concerns to management.

During our inspection of Lyme House we spoke with some of the people receiving a service. We also observed people being involved in various vocational activities. Some of the comments from people who lived at Lyme House were, “They are all good people working here and thanks to the staff, I am fantastic”, “I am having physio, here. The staff are really ‘buzzing’, they want me to walk, they want me to succeed and that’s a bonus” and “Its good here, I have no problems at all”.

We observed some positive interaction between support staff and people receiving a service. We saw members of staff being supportive, encouraging, motivational and sensitive in a non-patronising and appropriate manner.

We checked the medication procedures, in order to assess if medicines were correctly and safely administered.

We carried out a tour of the home to assess if it was safe, hygienic and comfortable for the people living there and for the members of staff working there.

We looked at the care/support records for three people living at Lyme House and the staffing rota lists for the previous month. This was to determine if the home was adequately staffed, to meet people's needs.

We looked at the homes records including, health and safety records, audits (checks) of quality assurance systems. This was to identify that people’s care records and records pertaining to the safety and wellbeing of people who lived in the home, were appropriately maintained and secure.

We spoke with four people living at Lyme House. They told us that the coaches (support workers) were generally, 'very respectful and sociable'. Other comments received were: "I am treated reasonably well. I do feel I am treated with dignity and respect," "This is

generally one of the better places I have lived" and "there is a good variety of activities, we go bowling at least once a week".

We observed people being supported in performing daily life skill activities. We were informed by the manager, 'people are encouraged to take part in various activities and daily tasks, to promote rehabilitation and independence'.

Other comments from relatives and external professionals were: "they keep me informed of everything and I can walk into the home at anytime," "they do a good job," "the workshops are fantastic for him," "overall I have no concerns," "He has moved on

somewhat, now less restricted.Definitely progressed more in this placement," "communication is very good, I visit the home or they keep me informed," "I have had patients placed in TRU for 12 years or so and have always found them to be sound in their

practice," "Over the years there have been a range of issues and I have liaised with TRU staff as necessary. At times I may get a phone call or an email," and "Overall I believe that TRU is providing satisfactory care and that they are working in the best interests of the client".